The ISCHEMIA trial found no significant difference between an invasive vs. a conservative strategy in patients with chronic coronary syndromes and moderate to severe ischemia at a mean of 3.2 years. However, the cumulative difference in the estimates of cardiac death between the invasive and conservative strategies tended to increase numerically over time (e.g., 0.3% in favor of the invasive strategy at two years and 1.3% at five years). Because the ISCHEMIA trial was not powered for cardiac mortality and did not focus on long-term follow-up, the rationale for a meta-analysis emerged.
At EuroPCR 2021, Navarese and colleagues present the results of a new meta-analysis of revascularization plus medical therapy versus medical therapy alone. A total of 19,806 patients with chronic coronary syndromes undergoing elective revascularization from 25 randomised trials were pooled, and outcomes were extracted at the longest available follow-up. The primary endpoint was cardiac death. Secondary endpoints were all-cause death, spontaneous myocardial infarction, any myocardial infarction and stroke.
The authors found a statistically significant 21% relative risk reduction in cardiac death with revascularization plus medical therapy (risk ratio 0.79, 95% confidence interval 0.67 to 0.93, p
There was a parallel significant reduction in spontaneous myocardial infarction with revascularization plus medical therapy (risk ratio 0.74, 95% confidence interval 0.64 to 0.86, pmyocardial infarction. No difference was noted in all the other secondary outcomes, including all-cause death.
Overall, this meta-analysis suggests that the benefits of revascularization and optimised medical therapy are additive, and their combination is required to achieve maximal and durable prevention of adverse events.
European Society of Cardiology